In discussing amputations of the lower limb, we've noted that each level has its own specific characteristics and challenges. The higher we move up the leg, the more joints are affected. A transtibial amputation involves the loss of the foot and one major joint, the ankle, while the transfemoral amputation involves the loss of two major joints, the knee and the ankle. Because transfemoral amputees are learning to cope with the loss of two major weight-bearing joints while transtibial amputees are learning to cope with the loss of only one, transfemoral amputees face more challenges learning to use a prosthesis and learning to walk again.

Now, our attention turns to two higher amputation levels – the hip disarticulation and the transpelvic amputation, also known as the hemipelvectomy.

These amputations mean the loss
of three joints – the hip, the knee and
the ankle. Although there's no way to
predict with certainty who will recover
best from an amputation, generally
people who have these high-level
amputations face much greater challenges.
Trying to overcome the loss of
three weight-bearing joints, rather than
one or two, is extremely complicated.
Living with a transfemoral amputation
is about 10 times as tough as living with
a transtibial amputation, and living
with a hip- or pelvic-level amputation
is perhaps 100 times harder. Walking,
standing, and even sitting balance
– something that most of us take for
granted – are greatly affected by amputations
at the hip or pelvis.

In addition to the physical impact
of these hip- and pelvic-level amputations,
they also have an increased
impact on self-image. There's increased
worry and stress as these surgeries start
encroaching on that personal area
involved in central body functions and
gender identity. Sometimes, the surgery
affects bowel, bladder or sexual functions.
Most of the time, it does not. But
either way, it starts involving the core
of the body. No longer does amputation
focus solely on the loss of some or all of
a limb. The emotional and psychosocial
aspects of these amputation levels can
be even greater than those for other
amputations.

I'm a big believer in support groups,
but, unfortunately, some people with
hip- or pelvic-level amputations may
feel left out and even isolated during
meetings. There are fewer people with
these high-level amputations, and often
the focus of support groups can be on
the issues and challenges faced by the
majority. The perspective is different.
Many of my patients who've had
amputations at the hip or pelvis tell
me that, while they enjoy some aspects
of a support group, they often don't
feel totally included or in sync with
the other members. They say some of
the issues brought up during meetings
may not be relevant to them, and their
own issues may not be relevant to the
others. If the group has a large number
of transtibial or transfemoral amputees,
the discussions may focus mainly on
the issues they face. A person with an
amputation below the hip and pelvis
may not be dealing with body core
function and image issues so he or she
likely wouldn't have anything to say
about these issues or even know what
to ask. It may be difficult for other
members of the group to understand or
connect emotionally with the concerns
of a person with a hip- or pelvic-level
amputation. Likewise, a person with
one of these high amputation levels
may be reluctant to bring up some
issues with those who aren't in a similar
situation.

“Could a greater miracle take place
than for us to look through each
other's eyes for an instant?”
– Henry David Thoreau/
essayist, poet, philosopher

The Hip Disarticulation

Hip disarticulation is the surgical
removal of the entire lower limb at the
hip level. A traditional hip disarticulation is done by separating the
ball from the socket of the hip joint,
while a modified version retains a small
portion of the proximal (upper) femur
to improve the contours of the hip disarticulation
for sitting. A hip disarticulation
results most often from trauma,
tumors and severe infections, such as
necrotizing fasciitis (commonly referred
to as flesh-eating bacteria). Less often,
it results from vascular disease and
complications of diabetes.

In past decades, hip disarticulation
was the common treatment for cases
of aggressive cancer in the lower limbs.
The surgeon's goal was to surgically
remove all of the tumor cells and
minimize any chance that the cancer
would recur so the amputation was
done all the way up in the hip area.
Today's treatment can include surgery,
chemotherapy or radiation modalities
to destroy tumor cells. Because of these
additional modalities, we can now
perform different types of surgery, and
the amputation site can be lower. We
can also do more limb salvages now.
Many patients, especially children, are
candidates for surgical resections and
replacement of missing skeleton with
donor bone or metal implants. Unfortunately,
salvage is not always possible,
and amputation is still an occasional
treatment for both childhood and adult
cancers of the lower limb.

The Transpelvic Amputation

Transpelvic amputation is the removal
of the entire lower limb, plus a portion
of the pelvic bones. It occurs in
a skeletal zone that can include, from
the socket on the outside to the spinal
column in the middle, the acetabulum,
ischium, rami, ilium and sacrum.
Transpelvic amputations result mostly
from very severe trauma, tumors,
and, specifically for spinal-cord-injury
patients, recurring severe ulcerations
and infections.

One extremely important aspect of
problems at the transpelvic level is the
higher risk of mortality. It's a sad truth
that many people don't survive the
disease or injury that can lead to amputation
at this level. And amputations at
this level carry a significant death rate
at the time of surgery or during hospitalization
immediately thereafter. Some
studies show that up to one-third of the
people hospitalized for transpelvic surgery
don't survive. Occasionally, these
injuries result from a crushing injury,
such as a cave-in at a construction site,
or an explosion. More frequently, the
injury results from a high-speed impact
with a post on a motorcycle, all-terrain
vehicle or snowmobile that causes
shearing trauma up through the pelvis.
With injuries like these, the person has
a more acute risk to life.

As previously noted, the transpelvic
amputation removes more than a
limb. By removing part of the pelvic
bones, and possibly the organs involved
in reproduction, bowel and bladder
functions, we're starting to lose parts
of the core center of the body. These
amputations, therefore, have profound
effects that extend beyond the loss of
a limb and walking function. They can
seriously impact sitting, with difficulties
in balance, support and weight distribution,
which can lead to a higher risk
for pressure ulcerations and sores. In
addition, these amputations can impact
bowel, bladder and sexual functions
and the symmetrical nature of the
lower core center of the body.

Surgery

Hip disarticulation and transpelvic
amputation surgeries frequently require
more variability at the amputation site than do other amputations of the lower limb. Ingenuity and creativity may be
demanded of the surgeon because the
amount of tissue lost to injury, disease
or infection is different in every case.
Also, there's not as much soft tissue to
work with for wound closure and padding
at these hip-level amputation sites
as we find in the calf or thigh areas.
When injury, disease or infection
requires amputation farther down the
leg, the person and the surgeon usually
agree it is best to do the amputation
at a level above the problem area. For
example, if there are severe problems
in the foot or ankle area that lead to
amputation, the amputation is usually
performed up in the calf, above the
problem area. This moves the amputation
outside the zone of injury, disease
or infection and usually provides fairly
normal tissue for padding. Moving up
the limb also better promotes healing
and comfort. Similarly, if there are
problems around the knee area, the
amputation site is typically moved up
to the thigh, again above the area of
injury, disease or infection.

But there's simply no room to move
higher when the injury, disease or
infection involves the hip or pelvic
area. This is the first amputation level
in the lower limb where there isn't an
option to keep moving up. It's a physical
reality; there's nowhere higher to
go, and the surgical team must do the
best it can under the circumstances.
That means greater challenges during
surgery. Surgeons need to be more creative
because they're working directly
in the problem zone. And because
they can't move the amputation site
to an area where there's normal tissue
for padding and closure, the closures
become more fragile.

This lack of extra soft tissue can
lead to scarring and a need for special
flaps for skin grafts. Age can also play
a factor. Scarring and grafts tend not
to be as big a problem for children as
they are for older adults. Many younger
children amaze their physicians and
therapists because they master walking
and sitting, learning to live with the
tremendous losses that amputations
around the hip bring. While adults also
must overcome these losses, it's far
more difficult for them to find similar
success with prostheses. Adults have to
work a heck of a lot harder at it! We'll
examine this concept in more detail in
Part 2 of this series.

The surgical team tries to shape the
bone surfaces so that they can take
weight while sitting and standing and
to use as much padding as possible to
cover the skeletal surfaces. Depending
on availability, the buttock or thigh
muscles are typically used for this.
The standard procedure is to use the
buttock muscles for padding over the
hip area. But if these muscles are lost,
the next choice
would be the
quadriceps muscle
in the front of the
thigh. Sometimes,
both the buttock
and thigh muscles
are lost – and
this is a really big
problem. Without
healthy muscle to
provide padding,
closure or coverage
often depends on
secondary healing – essentially allowing
Mother Nature to fill in the wound over time – and
eventually placing fragile skin grafts.
All of this makes the area much more
tender and prone to injury, infection or
both. Unfortunately, in some of these
cases, there simply are no good options.

The basic forms of amputation
in the hip area are the modified hip
disarticulation, the traditional hip
disarticulation and the varying degrees
of transpelvic amputation. In a modi-
fied hip disarticulation, the entire leg
is removed except for the very top
part of the femur (thigh bone) around
the greater and lesser trochanters
(two bump-shaped prominences of
bone where the tendons attach below
the neck of the femur) and the hip
joint's ball and socket. This provides a
smoother surface for the muscles to rest
over and can sometimes improve sitting
support.

In a traditional hip disarticulation,
the top part of the femur is removed,
and the hip's ball and socket are taken
apart. The entire femur, including the
ball, is removed, while the hip socket is
retained.

If the injury or disease involves the
socket or pelvic area, a transpelvic
amputation may be necessary. The hip
socket and parts of the pelvic bones
(acetabulum, ischium, rami, and
ilium) are removed. There are many
variations in how much of the pelvis
is removed, depending on the trauma,
infection or tumor. Sometimes, even
the sacrum (a triangular bone, which
is made up of five fused vertebrae just
above the coccyx, that forms the base
of the spine) may be removed, but we
try to avoid this, if possible. When the
sacrum is involved in the amputation,
it means sacrificing nerves related in
varying degrees to bowel, bladder or
sexual functions, or some combination
thereof.

A Common Misconception

Many people mistakenly assume that
the difference between a hip disarticulation
and a transpelvic amputation
is comparable to the distinction between a knee disarticulation and a
transfemoral (above-knee) amputation.
They think that by moving up to
the next higher amputation level there
will be abundantly more soft tissue
for wound closure and padding. But
the hip disarticulation and transpelvic
levels are extremely close to each other
skeletally, and both rely on the same
muscles for closure and padding. Any
problems with insufficient soft tissues
won't change dramatically by moving
to a higher level because a transpelvic
amputation generally occurs just two
inches above a hip disarticulation.
The soft tissue envelope doesn't really
change much in those two inches.
This misconception is widespread.
I've had medical professionals ask me,
“This hip disarticulation won't close.
Can't we just do a transpelvic amputation
so we can get it closed?” And I
have to say, “While the transpelvic
amputation will remove more bone,
it doesn't necessarily create more soft
tissue or let the soft tissue close with
much more ease. The amount of soft
tissue for closure changes very little.”

The Possible Impact on
Bowel, Bladder and Sexual
Functions

I'm often asked whether these amputation
levels will have any effect on
bowel, bladder or sexual functions. The
answer is, “Occasionally.” Typically, a
modified hip disarticulation or a true
hip disarticulation will have absolutely
no effect on these functions, but in special
circumstances they might. When
there are wounds near the rectal area
from the trauma, infection or tumor, a
temporary colostomy (an artificial anal
opening in the body from the colon) is
done for hygienic reasons. The colostomy
helps keep the wounds cleaner
during the time of wound care and
healing. The goal after wound healing
commonly is to remove the colostomy
and restore normal bowel function.
This usually proceeds as planned, but
in rare instances, the need for a colostomy
becomes permanent.

In a hip disarticulation, the organs
for urinary, bowel and sexual functions
usually retain function. But there
sometimes is a perception of change in
that area of the body. That's because
the bowel, bladder and sexual organs
are so close to the incisions and surgery
sites that they are perceived to be
involved. When I'm talking to people
before surgery, I tell them that while we
are not going to operate on the sexual
organs or rectum, the surgery may
still have an impact on those areas.
Typically, there's surgical swelling after
the amputation, and it may feel as if
those personal parts are being pushed
to the nonamputated side. As the
swelling goes down and the scars heal
and contract, it may feel as if the scar
tissue now is pulling things back over
to the amputated side. This back-andforth
phenomenon can be emotionally
disturbing. We think of that area of our
body as symmetrical. When surgery
results in “a shifting of the landscape,”
we're very concerned, even if function
is not affected.

The chance of alteration in bowel,
bladder or sexual functions increases
in a transpelvic amputation, which
involves the loss of part of the pelvic
bone. Nerve roots in the sacrum at the
bottom of the spinal column may be
divided. It's these sacral nerve roots that provide feeling for the bowel and
bladder areas. A colostomy for bowel
function or urostomy for bladder
function may be needed in some cases.
While the rectal area and sexual organs
are saved in other cases, they may be
repositioned. This concept of repositioning
can be difficult to visualize.

Repositioning occurs as surgical closure
rotates soft tissues, such as when soft
tissue from the front of the thigh is
pulled back and around to cover the
amputation site. The organs aren't
literally moved surgically from one
point to another; rather, they are gently
pulled, pushed, rotated or twisted
as soft tissue is repositioned so that
they are no longer symmetrical in the
middle.

Certainly, not everybody who undergoes
an amputation at the hip or pelvis
must contend with changes in any of
these functions. Unfortunately, some
people are impacted, more often those
who undergo a transpelvic amputation
rather than those who have a hip disarticulation.
There's no single answer for
everybody; it depends on the zone of
injury or disease.

The loss of any or all of these functions
can be even more emotionally
devastating than the loss of one or both
legs. And it makes for challenges in the
prosthetic fitting. At these amputation
levels, the prosthesis incorporates the
pelvis; in some cases, it may extend
all the way up to the ribs. We don't
want the prosthesis to push against
an ostomy (artificial opening) site,
however, and it becomes a real challenge,
prosthetically, to work around
these sites.

Rehabilitation and prosthetic
considerations for hip- and pelvic-level
amputations are very complex. In the
upcoming parts of this series, we will
discuss the importance of youth and
aging in recovery from these amputations
and offer further insights into
emotional and personal issues. From
the prosthetic point of view, we'll talk
about sockets that incorporate the
pelvis and lower body and the technical
issues of locating the hip joint. As we'll
see, the goals of recovery are not always
as straightforward as they can be for
lower-level amputations.

These high amputation levels truly
are closer to our core and soul, often
bringing us even closer to our own
mortality. We are confronted with
major changes and must reach deep
within ourselves to find new ways to
adapt. The course is not always clear,
and it is never the same for every
person. We don't always know where
the winds of fortune will take us, but
each of us must find a way to adjust to
them. It's been said, “We cannot direct
the wind, but we can adjust our sails.”